Sandbox:Sara.Zand

SUDDEN CARDIAC DEATH VICTIM

Recommendations for secondary prevention of sudden cardiac death

ICD implantation (Class I, Level of Evidence A):

❑ ICD implantation is recommended in patients with documented VF or hemodynamically not-tolerated VT in the absence of reversible causes

Amiodarone, Catheter ablation (Class IIb, Level of Evidence C) :

❑In patients with VT/VF, an indication for ICD, and no contraindication for amiodarone, amiodarone may be considered when an ICD is not available, contraindicated for concurrent medical reasons, or declined by the patient ❑In patients with sustained monomorphic VT or sustained polymorphic VT/VF triggered by a PVC with similar morphology and an indication for ICD, catheter ablation may be considered when an ICD is not available, contraindicated for concurrent medical reasons, or declined by the patient

The above table adopted from 2022 ESC Guideline

SUDDEN CARDIAC DEATH VICTIM

Recommendations for evaluation of sudden cardiac arrest victims

Medical history, Autopsy, Toxicology, Genetic testing (Class I, Level of Evidence B):

❑ Investigation of unexpected sudden death, especially in case of suspicion of inherited disease, should be made a public health priority ❑In cases of sudden death, it is recommended to collect a detailed description of circumstances of death, symptoms prior to death, the family history, and to review prior medical files ❑A comprehensive autopsy is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of age ❑In cases of SCD, it is recommended to retain samples suitable for DNA extraction and consult with cardiac pathologist when an inherited cause is suspected or the cause of death unexplained ❑Toxicology screens are recommended in sudden death cases with the uncertain cause of death ❑For SCD where the cause is known or suspected to be heritable, genetic testing targeted to the cause is recommended ❑Following SADS (sudden arrhythmic death syndrome), post-mortem genetic testing targeted to primary electrical disease is recommended when the decedent is young (,50) and/or the circumstances and/or family history support a primary electrical disease ❑When an autopsy diagnoses possible heritable cardiac disease, it is recommended to refer first-degree relatives for cardiac assessment ❑In non-autopsied cases of sudden death where inherited cardiac disease is suspected, it is recommended to refer first-degree relatives for cardiac assessment

(Class IIb, Level of Evidence C) :

❑Following sudden arrhythmic death syndrome, post-mortem genetic testing in the decedent for additional genes may be considered

(Class III, Level of Evidence B)

❑Following sudden arrhythmia death syndrome, hypothesis-free post-mortem genetic testing using exome or genome sequencing is not recommended

The above table adopted from 2022 ESC Guideline

post cardiac arrest survivors

Recommendations for evaluation of sudden cardiac arrest survivors

Extra cardiac cause (Class I, Level of Evidence B):

❑ The investigation of a SCA survivor without obvious extra-cardiac cause is recommended by a multidisciplinary team

Coronary angiogram (Class I, Level of Evidence C) :

❑ In electrically unstable patients after SCA, with suspicion of ongoing myocardial ischemia, a coronary angiogram is indicated

Brain and chect CT scan (Class I, Level of Evidence C)

❑In SCA survivors, brain/chest CT scan should be considered when patient characteristics, ECG, and echocardiography are not consistent with a cardiac cause

Blood sample, ECG, Cardiac imaging (Class I, Level of Evidence B)

❑In SCA survivors, collection of blood samples at presentation is recommended for potential toxicology and genetic testing ❑Retrieval of recordings from CIEDs and wearable monitors are recommended for all SCA survivors ❑In SCA survivors, repeated 12-lead ECGs during stable rhythm (including high precordial lead [[ECG]), as well as continuous cardiac monitoring, are recommended ❑Coronary imaging and CMR with LGE are recommended for evaluation of cardiac structure and function in all SCA survivors without a clear underlying cause ❑Sodium channel blocker test and exercise testing is recommended in SCA survivors without a clear underlying cause

Echocardiography (Class IC, Level of Evidence B)

❑Echocardiography is recommended to evaluate cardiac structure and function in all SCA survivors

Coronary vasospasm (Class IIb, Level of Evidence B)

❑In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be considered for the diagnosis of coronary vasospasm

The above table adopted from 2022 ESC Guideline

post cardiac arrest survivors

Recommendations for evaluation of sudden cardiac arrest survivors

Extra cardiac cause (Class I, Level of Evidence B):

❑ The investigation of a SCA survivor without obvious extra-cardiac cause is recommended by a multidisciplinary team

Coronary angiogram (Class I, Level of Evidence C) :

❑ In electrically unstable patients after SCA, with suspicion of ongoing myocardial ischemia, a coronary angiogram is indicated

Brain and chect CT scan (Class I, Level of Evidence C)

❑In SCA survivors, brain/chest CT scan should be considered when patient characteristics, ECG, and echocardiography are not consistent with a cardiac cause

Blood sample, ECG, Cardiac imaging (Class I, Level of Evidence B)

❑In SCA survivors, collection of blood samples at presentation is recommended for potential toxicology and genetic testing ❑Retrieval of recordings from CIEDs and wearable monitors are recommended for all SCA survivors ❑In SCA survivors, repeated 12-lead ECGs during stable rhythm (including high precordial lead [[ECG]), as well as continuous cardiac monitoring, are recommended ❑Coronary imaging and CMR with LGE are recommended for evaluation of cardiac structure and function in all SCA survivors without a clear underlying cause ❑Sodium channel blocker test and exercise testing is recommended in SCA survivors without a clear underlying cause

Echocardiography (Class IC, Level of Evidence B)

❑Echocardiography is recommended to evaluate cardiac structure and function in all SCA survivors

Coronary vasospasm (Class IIb, Level of Evidence B)

❑In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be considered for the diagnosis of coronary vasospasm

The above table adopted from 2022 ESC Guideline

vt storm

Recommendations for management of electrical storm

Sedation (Class I, Level of Evidence C):

❑ Mild to moderate sedation is recommended in patients with the electrical storm to reduce psychological distress and reduce sympathetic tone

Strucrural heart disease (Class I, Level of Evidence B) :

❑ Antiarrhythmic therapy with beta-blockers (non-selective preferred) in combination with intravenous amiodarone is recommended in patients with structural heart disease and electrical storm unless contraindicated ❑Catheter ablation is recommended in patients presenting with incessant VT or electrical storm due to sustained monomorphic VT refractory to antiarrhythmic drugs

Torsades depointes (Class I, Level of Evidence C)

❑ Intravenous magnesium with supplementation of potassium is recommended in patients with TdP ❑Isoproterenol or transvenous pacing to increase heart rate is recommended in patients with acquired LQT syndrome and recurrent TdP despite correction of precipitating conditions and magnesium

Procainamide (Class IIa, Level of Evidence B)

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT and presence of structural heart disease, intravenous procainamide should be considered

Intubation (Class IIa, Level of Evidence C)

❑Deep sedation/intubation should be considered in patients with an intractable electrical storm non-responsive drug treatment ❑Catheter ablation should be considered in patients with recurrent episodes of VT/VF triggered by a similar PVC, refractory to medical treatment or coronary revascularization

Quinidine (Class IIb, Level of Evidence C)

❑Quinidine may be considered in patients with coronary artery disease and electrical storm due to recurrent VT refractory to other antiarrhythmic drugs

The above table adopted from 2022 ESC Guideline

vt

Recommendations for acute management of sustained VT

DC cardiovertion (Class I, Level of Evidence B):

❑ DC cardioversion is recommended as the first-line therapy for hemodynamically not-tolerated sustained monomorphic ventricular tachycardia

DC cardiovertion (Class I, Level of Evidence C) :

❑ DC cardioversion is recommended as the first-line treatment for patients presenting with tolerated sustained monomorphic VT when anesthetic/sedation risk is low

Supraventricular tachycardia (Class IIa, Level of Evidence C)

❑ In patients presenting with a regular hemodynamically tolerated wide QRS complex tachycardia suspected for supraventricular tachycardia, administration of adenosine or vagal maneuvers should be considered

Procainamide (Class IIa, Level of Evidence B)

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT and presence of structural heart disease, intravenous procainamide should be considered

Flecainide, ajmaline, sotalol (Class IIb, Level of Evidence B)

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT in the absence of significant structural heart disease, flecainide, ajmaline, or sotalol may be considered

Verapamil (Class III, Level of Evidence B)

❑Intravenous verapamil is not recommended in wide QRS complex tachycardia of unknown mechanism

The above table adopted from 2022 ESC Guideline

polymorphic vt

Polymorphic Ventricular arrhythmia

Underlying etiology

Acute ischemia

External precipitating factors

Polymorphic Ventricular Arrhythmia triggered by unifocal PVC

Acquired long QT

Primary electrical disease

Approach to STEMI

Treatment of underlying condition (Class I)

Catheter ablation (Class IIa) Quinidine (Class IIb)

Remove precipitating factors (Class I) Mg++/K+ i.v.(Class I) Isoproterenol (Class I) Pacing (Class I)

Brugada, Early repolarization syndrome

Idiopathic VF

Long QT, CPVT

Recurrent Ventricular arrhythmia

Recurrent Ventricular arrhythmia

Recurrent Ventricular arrhythmia

Isoproterenol (Class IIa) Quinidine (Class IIa) Catheter ablation (Class IIa)

Isoproterenol (Class IIa) Quinidine (Class IIa) Verapamil (Class IIa Catheter ablation of PVC triggers (Class IIa)

Beta-blocker (Class I) Pacing (Class I) Mg++/K+ i.v (Class I) Antiarrhythmic drugs according to underlying disease (Class 2a) Autonomic modulation (Class 2a)

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

Recurrent ventricular arrhythmia

Recurrent ventricular arrhythmia

Recurrent ventricular arrhythmia

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

Deep sedation/ intubation (Class IIa) Mechanical circulatory support (Class IIb)

The above algorithm adopted from 2022 ESC Guideline

AS

V1

_

+

Positive inferior leads

Positive inferior leads

0

1,2

3

3

1,2

0

V3

V3

V3

Left lateral

Left posterolateral

V1/1 ratio

_

+

Right posterior

Right paraseptal

<1

≥1

_

+

Lead 2, Notched QS

Left posterolateral

Right lateral

Nodo-Hisian

Yes

NO

_

+

Deep coronary sinus

Left paraseptal

Nodo-Hisian

Right atrium

a1

Orthodromic AVRT

Pre-excitation on resting ECG

Yes

NO

Ablation candidate, willing to undergo ablation

Ablation candidate, patient prefers ablation

N0

Yes

Yes

NO

Flecainide or propafenone in the absent of structural heart disease (class 2a)

Amiodarone, betablocker, diltiazem, dofetilide, sotalol, verapamil (class 2b)

Catheter ablation (class 1)

Catheter ablation (class 1)

Betablocker, diltiazem, verapamil (class1)

Flecainide, propafenone in the absent of structural heart disease (class 2a)

Amiodarone, digoxin, dofetilide, sotalol (class 2b)

If ineffective, consider ablation

If ineffective, consider ablation

If ineffective, consider ablation

If ineffective, consider ablation

If ineffective, consider ablation

Characteristics	Favors SAVR	Favors TAVI	Favors palliation
Age/life expectancy	Younger age/longer life expectancy	Older age/fewer expected remaining years of life	Limited life expectancy
Valve anatomy	BAV Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus	Calcific AS of a trileaflet valve
Prosthetic valve preference	Mechanical or surgical bioprosthetic valve preferred Concern for patient–prosthesis mismatch (annular enlargement might be considered)	Bioprosthetic valve preferred Favorable ratio of life expectancy to valve durability In TAVI valve area is larger than same size SAVR
Concurrent cardiac conditions	Aortic dilation Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF	Severe calcification of the ascending aorta (porcelain aorta)	Irreversible severe LV systolic dysfunction Severe MR attributable to annular calcification
Noncardiac conditions		Severe lung, liver, or renal disease Mobility issues (high procedural risk with sternotomy)	Symptoms likely attributable to noncardiac conditions Severe dementia Moderate to severe involvement of ≥2 other organ systems
Frailty	Not frail or few frailty measures	Frailty likely to improve after TAVI	Severe frailty unlikely to improve after TAVI
Estimated procedural or surgical risk of SAVR or TAVI	SAVR risk low TAVI risk high	TAVI risk low to medium SAVR risk high to prohibitive	Prohibitive SAVR risk (>15%) or post-TAVI life expectancy <1 y
Procedural specific impediments	Valve anatomy, annular size, or low coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI	Previous cardiac surgery with at-risk coronary grafts Previous chest irradiation	Valve anatomy, annular size, or coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI
Goals of Care and patient preferences and values	Less uncertainty about valve durability Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and quality of life Avoid vascular complications Longer hospital stay, pain in recovery period	Uncertainty about valve durability and possible repeat intervention Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and quality of life Shorter hospital stay, less postprocedural pain	Life prolongation not an important goal Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pace maker implantation

The above table adopted from 2020 AHA Guideline

Recommendations for choice of Mechanical Versus Bioprosthetic AVR

(Class I, Level of Evidence C):

❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve re-intervention ❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

(Class IIa, Level of Evidence B):

❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy ❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors ❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

(Class IIb, Level of Evidence B):

❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

The above table adopted from 2020 AHA Guideline

Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate
(Class I, Level of Evidence A):
❑ SAVR is recommended for symptomatic and asymptomatic severe AS, and any indication for AVR, who are < 65 years and life expectancy >20 year ❑Either SAVR or transfemoral TAVI is recommended in symptomatic severe AS who are 65-80 years after evaluation about life expectancy and valve durability ❑TAVI is recommended in symptomatic severe AS who are >80 years or younger patients with life expectancy <10 years and no anatomic contraindication for transfemoral TAVI ❑ TAVI is recommended in symptomatic patients with severe AS in any age and high surgical risk or prohibitive for surgery when predicted survival is > 12 months after TAVI with acceptable quality of life
(Class I, Level of Evidence B):
❑SAVR is recommended in preference to TAVI in asymptomatic severe AS and abnormal exercise stress test, very severe AS, rapid progression, and elevated BNP ❑ In asymptomatic severe AS in age ≤ 80 years of age and LVEF < 50 and no anatomic contraindications for transfemoral TAVI, making decision between TAVI and SAVR is similar to symptomatic patients
(Class I, Level of Evidence C):
❑For symptomatic severe AS when predictive survival is <12 months after TAVI or SAVR and minimal improvement in quality of life is expected, palliative care is recommended
(Class IIb, Level of Evidence C):
❑For critically ill patients with severe AS, percutaneous aortic ballon dilation is a bridge to TAVI or SAVR

The above table adopted from 2020 AHA Guideline

Abbreviations: SAVR: Surgical aortic valve replacement; TAVI: Transcutaneous aortic valve implantation; AS: Aortic stenosis; LVEF:Left ventricular ejection fraction ;

• Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
• MVA >1.5 cm²
• Left atrial thrombus
• More than mild mitral regurgitation
• Severe or bi-commissural calcification
• Absence of commissural fusion
• Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
• Concomitant [[cor

b1

Class	Level	Recommendations
I	C	Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
IIa	B-NR	Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
IIa	C	Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.

c1

Aortic Regurgitation

Moderate Aortic Regurgitation>

Severe Aortic Regurgitation ❑VC>0.6cm ❑ Holodiastolic aortic flow reversal ❑ RVol≥60 ml ❑ RF≥ 50% ❑ ERO≥0.3cm²

Other cardiac surgery

Symptomatic (stage D)

Asymptomatic (stage C)

AVR (Class IIa)

❑ LVEF≤ 55% (stage C2)

❑ Other cardiac surgerysurgery

❑ LVEF> 55% AND ❑ LVESD > 50mm (LVESD>25mm/m² )

❑ Progressive decrese in LVEF to <55%-60% or increase in LVEDD to >65mm on at least 3 studies

AVR (Class I)

AVR (Class I)

AVR (Class I)

AVR (Class IIa)

Low surgical risk

AVR (Class IIb)

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice

The above algorithm adopted from 2020 AHA Guideline

a1

Tricuspid regurgitation

Progressive TR (Stage B)

At time of left sided valve surgery

Severe TR (Stage C,D)

Annular dilation> 4 cm, or perior righ heart failure

Asymptomatic (Stage C)

At time of left sided valve surgery

Right heart failure (Stage D)

TV surgery (2a)

Primary TR with progressive RV dilation or systolic dysfunction

TV surgery (1)

TV surgery (2b)

Primary TR

Prior left sided valve surgery

Secondary TR

TV surgery (2a)

Absent of severe pulmonary hypertension or RV systolic dysfunction

Poor response to medical therapy

TV surgery (2b)

Annular dilation without pulmonary hypertension or left sided disease

TV surgery (2a)

Abbreviations: TR: Tricuspid Regurgitation; TV: Tricuspid valve; RV: Right ventricle

The above algorithm adapted from 2020 AHA Guideline

A

Recommendations for management of prosthetic valve dysfunction

Mechanical prosthetic thrombosis (Class I, Level of Evidence B):

❑ In patients with obstructive thrombosis who are critically ill patients without serious comorbidities, urgent or emergency valve replacement is recommended

(Class IIa, Level of Evidence B):

❑Fibrinolysis (using recombinant tissue plasminogen activator 10 mg bolus + 90 mg in 90 min with UFH or streptokinase 1500 000 U in 60 min without UFH) should be considered when surgery is very high risk or is not available , or for thrombosis of right-sided prostheses

(Class IIa, Level of Evidence C):

❑Surgery should be considered for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism

Bioprosthetic thrombosis (Class I, Level of Evidence C):

❑ In bioprosthetic valve thrombosis, anticoagulation using a VKA and/or UFH is recommended before considering re-intervention

(Class IIa, Level of Evidence B):

❑ Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion causing elevated gradients, at least until resolution

Hemolysis and paravalvular leak (Class I, Level of Evidence C):

❑ Reoperation is considered when a paravalvular leak is related to endocarditis or leading haemolysis requiring repeated blood transfusions or causes severe heart failure symptoms

(Class IIa, Level of Evidence B):

❑Transcatheter closure is recommended for suitable paravalvular leaks with clinically significant regurgitation and/or haemolysis in high risk patients for surgery

(Class IIa, Level of Evidence C):

❑ Transcatheter or surgical closure of clinically significant paravalvular leaks is considered based on patient risk status, leak morphology, and local expertise

Bioprosthetic failure (Class I, Level of Evidence C):

❑Reoperation is recommended in symptomatic patients with severe regurgitation or a significant increase in transprosthetic gradient (after exclusion of valve thrombosis)

(Class IIa, Level of Evidence B):

❑ Desion of Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team based on anatomic considerations, features of the prosthesis, and high risk patients for surgery or inoperable patients

(Class IIb, Level of Evidence B):

❑ Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in high risk patients for surgery

(Class IIa, Level of Evidence C):

❑Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if reoperation is low risk

The above table adopted from 2021 ESC Guideline

Abbreviations: UFH: Unfractionated heparin; VKA: Vitamin K antagonist

B

Antithrombotic therapy for valve prostheses

Mechanical heart valve

Bioprosthetic heart valve

VKA lifelong (Class I)

MVR/TVR

SAVR

TAVI

CAD

Other indications for oral anticoagulation

Other indications for oral anticoagulation

Other indications for oral anticoagulation

Add low-dose ASA in low risk patients for bleeding (Class IIb)

NO

Yes

Subtherapeutic INR for major planned invasive procedure

OAC for 3 months (Class IIa)

OAC long-term (Class I)

Bridging anticoagulation with UFH or LMWH (not required for minor surgeries) (Class I)

NO

Yes

SAPT or OAC for 3 months (Class IIa)

OAC long-term (Class I)

NO

Yes

SAPT long-term (Class I)

OAC long-term (Class I)

The above algorithm adopted from 2021 ESC Guideline

Abbreviations: ASA: acetylsalicylic acid; AF: Atrial fibrillation; CAD: Coronary artery disease; TAVI: Transcatheter aortic valve implantation; DAPT: Dual antiplatelet therapy; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricular; SAVR:Surgical aortic valve replacement; OAC:Oral anticoagulation; SAPT:Single antiplatelet therap; UFH: Unfractionated heparin; VKA:Vitamin K antagonist; TVR:Tricuspid valve replacement or repair; MVR:Mitral valve replacement or repair

C

Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods

Management of antithrombotic therapy in the perioperative period (Class I, Level of Evidence C):

❑It is recommended discontinuation of VKA prior to elective surgery to aim for an INR <1.5 ❑Bridging of OAC is recommended in patients with any of the following: Mechanical prosthetic heart valve AF with significant mitral stenosis AF with a CHA2DS2-VASc score ≥ 3 for women or 2 for men Acute thrombotic event within the previous 4 weeks High acute thrombotic risk ❑In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to initiate either UFH or LMWH 12-24 h after surgery ❑ Maintaning aspirin therapy , if indicated, is recommended in patients undergoing surgery during the periprocedural period ❑In patients treated with DAPT after recent PCI (within 1 month) requiring heart valve surgery in the absence of an indication for OAC, starting the P2Y12 inhibitor postoperatively is recommended

(Class I, Level of Evidence B):

❑For bridging, therapeutic doses of either UFH or subcutaneous LMWH are recommended

(Class I, Level of Evidence C):

❑ Re-initiation of the VKA on the first postoperative day is recommended in patients with mechanical valve

(Class IIb, Level of Evidence C):

❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism

Concomitant antiplatelet therapy (Class I, Level of Evidence B):

❑If the risk of stent thrombosis is low, in patients undergone PCI or after ACS requiring long-term OAC, early cessation (≤1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended ❑ In patients treated with an OAC, discontinuation of antiplatelet treatment is recommended after 12 months

(Class IIa, Level of Evidence C):

❑If the risk of stent thrombosis is high, in patients undergone PCI or after ACS requiring both OAC and antiplatelet therapy, triple therapy with aspirin, clopidogrel and OAC for longer than 1 week should be considered with the total duration (≤1 month)

(Class IIa, Level of Evidence B):

❑In patients with mechanical heart valve treated with a VKA and low risk for stent thrombosis and HAS-BLED ≥ 3 , clopidogrel alone should be considered for up to 12 months ❑In patients requiring aspirin and/or clopidogrel in addition to VKA, target INR should be considered in the lower part of the recommended target

Surgical valve replacement (Class I, Level of Evidence B):

❑For all patients with an mechanical heart valve prosthesis, OAC using a VKA is recommended lifelong ❑ For patients with biological heart valve, OAC is recommended if they have other indications for anticoagulation

(Class IIa, Level of Evidence B):

❑ In patients with biological heart valve and AF, NOACs should be considered over VKA after 3 months following surgical implantation ❑ In patients with an aortic biological heart valve, low-dose aspirin (75-100 mg/day) or OAC using a VKA should be considered for the first 3 months after surgical implantation ❑ In patients with a mitral or tricuspid biological heart valve, OAC using a VKA should be considered for the first 3 months after surgical implantation

(Class IIb, Level of Evidence C):

❑ In patients with mechanical heart valve and evidence of atherosclerotic disease and low risk of bleeding, The addition of low-dose aspirin (75-100 mg/ day) to VKA may be considered in selected patients ❑NOACs may be considered over VKA within 3 months following surgical implantation of a biological heart valve in mitral position in patients with AF

(Class IIa, Level of Evidence C):

❑ Low-dose aspirin (75-100 mg/day) in addition to VKA should be considered after thromboembolism despite an adequate INR

(Class III, Level of Evidence B):

❑NOACs are not recommended in patients with a mechanical valve prosthesis

Surgical valve repair (Class IIa, Level of Evidence C):

❑OAC with VKA should be considered during the first 3 months after mitral and tricuspid repair ❑SAPT with low-dose ASA (75-100 mg/day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications to

Transcatheter aortic valve replacement (Class I, Level of Evidence B):

❑OAC is recommended lifelong for TAVI patients who have other indications for OAC

(Class I, Level of Evidence A):

❑Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC

(Class III, Level of Evidence B):

❑ Routine use OAC is not recommended after TAVI in patients with no baseline indication for OAC

The above table adopted from 2021 ESC Guideline

Abbreviations: ACS: Acute coronary syndrome; AF: Atrial fibrillation; NOAC: Non-vitamin K antagonist oral anticoagulant; TAVI: Transcatheter aortic valve implantation; DAPT: Dual antiplatelet therapy; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricular; PCI:Percutaneous coronary intervention; OAC:Oral anticoagulation; SAPT:Single antiplatelet therap; UFH: Unfractionated heparin; VKA:Vitamin K antagonist

D

Recommendations for prosthetiv valve disease
Mechanical protheses (Class I, Level of Evidence C):
❑A mechanical prosthesis is recommended according to the desire of the informed patient and NO contraindications to long term anticoagulation ❑A mechanical prosthesis is recommended in patients at risk of structural valve deterioration
(Class IIa, Level of Evidence C):
❑A mechanical prosthesis should be considered in patients already on anticoagulation because of a mechanical prosthesis in another valve position ❑A mechanical prosthesis should be considered in patients with a reasonable life expectancy and high risk for redo valve surgery or TAVI
(Class IIa, Level of Evidence B):
❑A mechanical prosthesis should be considered in patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position
(Class IIb, Level of Evidence C):
❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism
Biological prothesis (Class I, Level of Evidence C):
❑A bioprosthesis is recommended according to the desire of the informed patient ❑A bioprosthesis is recommended when anticoagulant theray is contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation and low life expectancy ❑A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good anticoagulation
(Class IIa, Level of Evidence C):
❑A bioprosthesis should be considered in patients for whom there is a low likelihood and/or a low operative risk of future redo valve surgery ❑A bioprosthesis should be considered in young women in the age of pregnancy ❑A bioprosthesis should be considered in patients aged >65 years for a prosthesis in the aortic position or aged >70 years in a mitral position
(Class IIb, Level of Evidence B):
❑A bioprosthesis may be considered in patients already on long-term NOACs for whom are high risk for thromboembolism

The above table adopted from 2021 ESC Guideline

Abbreviations: TAVI: Transcatheter aortic valve implantation; AF: Atrial fibrillation; NOAC: Non-vitamin K antagonist oral anticoagulant;

G

Recommendations for intervention in tricuspid valve disease
Tricuspid stenosis (Class I, Level of Evidence C):
❑ Surgery is recommended in symptomatic patients with severe tricuspid stenosis ❑ Surgery is recommended in patients with severe tricuspid stenosis undergoing left-sided valve intervention
Primary Tricuspid Regurgitation (Class I, Level of Evidence C):
❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction
Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):
❑Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery
Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):
❑Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery
Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):
❑Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery ❑Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension
Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):
❑Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients

The above table adopted from 2021 ESC Guideline

=F

Management of clinically significant rheumatic mitral stenosis (MVA ≤ 1.5 cm2)

Symptoms

NO

Yes

High risk of embolism or hemodynamic decompensation

Contraindication to PMC

Yes

NO

NO

Yes

PMC if favourable characteristics for PMC or contraindication for surgery Surgery if unfavourable charactristics for PMC

Exercise test

Contraindication or high risk for surgery

Surgery

Symptoms

Yes

NO

NO

Yes

PMC

Favourable anatomical characteristics

Follow-up

Contraindication to or unfavourable characteristics for PMC

NO

Yes

NO

Yes

Surgery

PMC

PMC

Surgery

Abbreviations: PMC: Percutaneous mitral commissurotomy; MVA:Mitral valve area

The above algorithm adopted from 2021 ESC Guideline

K

Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)
(Class I, Level of Evidence B):
❑ PMC is recommended in symptomatic patients with favourable characteristics for PMC
(Class I, Level of Evidence C):
❑PMC is recommended in any symptomatic patients who are high risk for surgery ❑Mitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility
(Class IIa, Level of Evidence C):
❑PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy and favourable clinical characteristics for PMC ❑PMC should be considered in asymptomatic patients with favourable clinical and anatomical characteristicsc for PMC and: High thromboembolic risk (history of systemic embolism, spontaneous contrast in the left artium, new-onset or paroxysmal AF), and/or High risk of hemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major non-cardiac surgery, desire for pregnancy)

The above table adopted from 2021 ESC Guideline

Abbreviations: PMC: Percutaneous mitral commissurotomy; AF: Atrial fibrillation; LA: Left atrium; MVA:Mitral valve area ;

• Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
• MVA >1.5 cm²
• Left atrial thrombus
• More than mild mitral regurgitation
• Severe or bi-commissural calcification
• Absence of commissural fusion
• Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
• Concomitant coronary artery disease requiring bypass surgery

P

Management of patients with chronic severe secondary mitral regurgitation

Symptomatic despite medical therapy

*Optimazing medical therapy CRT implantation if indicated

Severe comorbidities or life expectancy < 1 year

Yes

NO

Palliative care

Presence of CAD or other cardiac disease

Yes

NO

Appropriate for surgery

Persisting severe symptomatic secondary MR

Valve surgery if fulfilling criteria

Yes

NO

CABG, MV surgery

PCI, TAVI

Persisting severe symptomatic secondary MR

Yes Appropriate for valve surgery

NO Close follow-up

Yes MV surgery

NO End-stage LV, RV failure

Yes Heart transplantation, left ventricular assist devices palliative care

NO Fulfilling criteria suggesting an increased chance of responding to TEER

Yes=TEER

NO Heart transplantation, left ventricular assist devices palliative care, TEER in selected cases or other transcatheter valve therapy if applicable for symptoms improvement

The above algorithm adopted from 2021 ESC Guideline

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; MV:Mitral valve ; PCI:Percutaneous coronary intervention; LVAD: Left ventricular assist devices; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation; CAD: Coronary artery disease

T

Recommendations for intervention in chronic severe secondary mitral regurgitation
(Class I, Level of Evidence B):
❑ Valve surgery/intervention is recommended in symptomatic severe secondary MR despite GDMT or CRT ❑Valve surgery is recommended in patients undergoing CABG or other cardiac surgery
(Class IIa, Level of Evidence B):
❑TEER should be considered in selected symptomatic patients, not suitable for surgery and high likelihood of responding to TEER
(Class IIa, Level of Evidence C):
❑ In symptomatic inoperable patients, PCI (and/orTAVI) possibly followed by TEER (in case of persisting severe secondary MR) should be considered
(Class IIb, Level of Evidence C) :
❑ Valve surgery may be considered in symptomatic patients who are appropriate for surgery ❑In high-risk symptomatic patients not eligible for surgery and low likelihood of responding to TEER, making decision about TEER procedure or other transcatheter valve therapy and evaluation for ventricular assist device or heart transplant should be considered

The above table adopted from 2021 ESC Guideline

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; ERO:Effective regurgitation orifice area ; PCI:Percutaneous coronary intervention; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation

U

Management of patients with severe chronic primary mitral regurgitation

Symptoms

Yes

NO

Determining the risk of surgery

LVEF ≤ 60% or LVESD ≥ 40 mm

High risk of futility Palliative therapy

High risk for surgery or inoperable

Yes

NO

Yes

NO

Surgery

New onset AF or SPAP>50 mmHg

TEER if anatomically suitable, optimal heart failure therapy

Surgery (repair whenever possible)

Yes, surgery

NO

High likelihood of durable repair, low surgical risk, and LA dilatation

NO

Yes

Follow-up

Surgical mitral valve repair

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

The above algorithm adopted from 2021 ESC Guideline

I

Recommendations for intervention in primary mitral regurgitation
(Class I, Level of Evidence B):
❑ Mitral valve repair is considered when the results of surgical technique are expected to be durable ❑ Surgery is recommended in low risk symptomatic patients ❑ Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD ≥ 40 mm and/or LVEF ≤ 60%)
(Class IIa, Level of Evidence B):
❑ Surgery is recommended in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg) ❑Surgical mitral valve repair is recommended in low-risk asymptomatic patients with LVEF > 60%, LVESD <40 mmd and significant LA dilatation (volume index ≥60 mL/m2 or diameter ≥55 mm)
(Class IIb, Level of Evidence B) :
❑TEER may be considered in symptomatic patients who are inoperable due to high surgical risk, with echocardiographic criteria of eligibility

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

The above table adopted from 2021 ESC Guideline

O

Recommendations for intervention in aortic stenosis

Symptomatic aortic stenosis:

(Class I, Level of Evidence B):

❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) ❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

(Class IIa, Level of Evidence C):

❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction ❑ Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

(Class III, Level of Evidence C) :

❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

Asymptomatic severe aortic stenosis :

(Class I, Level of Evidence B):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

(Class I, Level of Evidence C):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

(Class IIa, Level of Evidence B):

❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

(Class IIa, Level of Evidence C):

❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

(Class IIa, Level of Evidence B):

❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following: Very severe aortic stenosis (mean gradient ≥60 mmHg or Vmax > 5 m/s Severe valve calcification ( assessed by CCT) and Vmax progression ≥0.3 m/s/year Elevated BNP levels (>3× age- and sex-corrected normal range) confirmed by repeated measurements and without other causes

Type of intervention:

(Class I, Level of Evidence C):

❑Aortic valve interventions should be performed in an experienced center

(Class I, Level of Evidence B):

❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI ❑SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

(Class I, Level of Evidence A):

❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

(Class IIb, Level of Evidence C):

❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI. ❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity

The above table adopted from 2021 ESC Guideline

R

Clinical characteristics	Favours TAVI	Favours SAVR
Lower surgical risk	_	+
Higher surgical risk	+	_
Younger age	_	+
Older age	+	_
Previous cardiac surgery (CABG)	+	_
Severe frailty	+	_
Endocarditis	_	+
Anatomical and procedural factors
TAVI feasible via transfemoral approach	+	_
Inaccessable Transfemoral approach or SAVR feasible	_	+
Sequelae of chest radiation	+	_
Porcelain aorta	+	_
High likelihood of severe patient-prosthesis mismatch (AVA <0.65 cm2/m2 BSA)	+	_
Severe chest deformity or scoliosis	+	_
Unsuitable aortic annular dimensions for TAVI device	_	+
Bisuspid aortic valve	_	+
Unfavourable valve morphology for TAVI (high risk of coronary obstruction due to low coronary ostia or heavy leaflet/LVOT calcification	_	+
Thrombus in aorta or left ventricle	_	+
Concomitant cardiac conditions requiring interventio
Significant multi-vessel CAD requiring surgical revascularization	_	+
Severe primary mitral valve disease	_	+
Severe tricuspid valve disease	_	+
Significant dilatation/aneurysm of the aortic root and/or ascending aorta	_	+
Septal hypertrophy requiring myomectomy	_	+

Abbreviations: AV: Aortic valve; AVA: Aortic valve area; LVOT: Left ventricular outflow tract ; SAVR: Surgical aortic valve replacement; TAVI: Transcatheter aortic valve implantation; BSA: Body surface area; CAD: Coronary artery disease

The above table adopted from 2021 ESC Guideline

Y

Valvular AS Assessment of velocity, gradient

Low-gradient AS Vmax < 4 m/s ΔPm < 40 mmHg

High-gradient AS Vmax ≥ 4 m/s, ΔPm ≥ 40 mmHg

AVA ≤ 1.0 cm2

High flow status

Yes Determination of flow status

NO Moderate AS

Yes Assessment of normal flow condition

NO Severe AS

Normal flow SVi > 35 mL/m2

Low flow SVi ≤ 35 mL/m2

Severe AS unlikely

LVEF ≥ 50%

NO DSE flow reservec

Yes CCT to assess AV calcification

NO, CCT to assess AV calcification

Yes, AVA ≤ 1.0 cm2

Yes Severe AS

NO Pseudo-severe AS

Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity

The above table adopted from 2021 ESC Guideline

• High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
• The definition of Normal flow by pulsed Doppler echocardiography is  :

  Cardiac index 4.1 L/min/m2 in men and women

  SVi 54 mL/m2 in men, 51 mL/m2 in women

• DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
• Pseudo-severe aortic stenosis is defined as AVA >1.0 cm2 with increased flow.
• CT measurement of aortic valve calcification (Agatston units) for definition of high likely severe AS:

  men >3000, women>1600

  Likely: men >2000, women >1200

  Unlikely: men <1600, women <800

E

Management of aortic regurgitation

Significant enlargement of ascending aorta

Severe aortic regurgitation

Surgery

Symptoms

Yes Surgery

NO LVEF≤ 50% or LVESD > 50 mm (or > 25 mm/m2 BSA)

Yes Surgery

The above algorithm adopted from 2021 ESC Guideline

D

Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm

Severe aortic regurgitation (Class I, Level of Evidence B):

❑ Surgery is recommended in symptomatic patients regardless of LV function ❑ Surgery is recommended in asymptomatic patients with LVESD > 50 mm or LVESD > 25 mm/m2 BSA (in patients with small body size) or resting LVEF ≤ 50%

(Class IIb, Level of Evidence C):

❑ Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤ 55%, in low risk condition ❑Aortic valve repair may be considered in selected patients at experienced centres when durable results are expected

(Class I, Level of Evidence C) :

❑ Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve

Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation (Class I, Level of Evidence B):

❑ Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation

(Class I, Level of Evidence C):

❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm

(Class IIa, Level of Evidence C):

❑ Ascending aortic surgery is recommended with ascending aorta size of: >_55 mm in all patients >_45 mm in Marfan syndrome and additional risk factors or in the presence of TGFBR1 or TGFBR2 mutation (including Loeys Dietz syndrome) Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year >_50 mm in the presence of a bicuspid valve with additional risk factorsd or coarctation ❑ In the presence of primarily indication for the surgery of aortic valve, replacement of the aortic root or tubular ascending aorta should be considered when ≥ 45 mm

Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete

The above table adopted from 2021 ESC Guideline

W

Recommendations for management of atrial fibrillation in valvular heart disease

NOAC (Class I, Level of Evidence A):

❑ In AF patients and mitral regurgitation, aortic regurgitation, and aortic stenosis, NOACs are preferred to VKAs for prevention of stroke .

NOAC (Class III, Level of Evidence C):

❑ NOACs is not recommended in patients with AF and moderate to severe mitral stenosis

AF ablation:(Class IIa, Level of Evidence A) :

❑ Concomitant AF ablation should be considered in patients undergoing valve surgery with respect to risk factors of recurrence (LA dilatation, years in AF, age, renal dysfunction, and other cardiovascular risk factors

LAA occlusion : (Class IIa, Level of Evidence B)

❑ LAA occlusion should be considered to reduce the thromboembolic risk in patients with AF and a CHA2DS2VASc score ≥ 2 undergoing valve surgery

Abbreviations: AF: Atrial fibrillation; LA: Left atrium; LAA: Left atrial appendage; NOAC:Non vitamin-K antagonist oral anticoagulant ; OAC:Oral anticoagulation; VKA: Vitamin-K antagonist

The above table adopted from 2021 ESC Guideline

Q

Recommendations for management of CAD in valvular heart disease

Coronary angiography (Class I, Level of Evidence C):

❑ Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: History of cardiovascular disease Suspected myocardial ischemia Left ventricular systolic dysfunction In men >40 years of age and postmenopausal women One or more cardiovascular risk factors Evaluation of severe mitral regurgitation

Coronary CT angiography (Class I, Level of Evidence C):

❑ Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD

CABG:(Class I, Level of Evidence C) :

❑ CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70%

CABG : (Class IIa, Level of Evidence C)

❑ CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70%

PCI : (Class IIa, Level of Evidence C)

❑ PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments ❑ PCI is recommended in patients undergoing transcatheter mitral valve intervention and coronary artery diameter stenosis > 70% in proximal segments

Abbreviations: CAD: Coronary artery disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; TAVI:Transcatheter aortic valve implantation; VHD:Valvular heart disease

The above table adopted from 2021 ESC Guideline

Endocarditis prophylaxis

• Antibiotic prophylaxis should be considered for high-risk procedures in patients with prosthetic valves including:

  Transcatheter valves

  Valve repaired using prosthetic material

  History of previous episode(s) of infective endocarditis

• Specific attention to dental and cutaneous hygiene and strict aseptic measures during any invasive procedure are recommended.
• Antibiotic prophylaxis should be considered in dental procedures including the manipulation of the gingival or periapical region of the teeth or manipulation of the oral mucosa

Recommendations for anticoagulant therapy in valvular heart disease

NOAC (Class I, Level of Evidence A):

❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score

VKA (Class I, Level of Evidence C):

❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS

VKA:(Class IIa, Level of Evidence B) :

❑ Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement

NOAC : (Class III: Harm, Level of Evidence B)

❑ NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation

Abbreviations: CAD: Coronary artery disease; VKA: Vitamin-K antagonist; AF: Artial fibrillation

The above table adopted from 2020 AHA Guideline

Prophylaxis for rheumatic fever

• Antibiotic therapy of group A Streptococcus infection throat is necessary in primary prevention of rheumatic fever.
• Screening with echocardiographic in combination with secondary prevention by antibiotic prophylaxis in children with evidence of latent rheumatic heart disease are considered to reduce the prevalence of disease in endemic regions.
• Recommendation for secondary long-term prophylaxis against rheumatic fever in patients with established rheumatic heart disease is benzathine benzyl penicillin 1.2 MUI every 3 to 4 weeks over 10 years.
• Lifelong prophylaxis is recommended in high-risk patients based upon the severity of VHD and exposure to group A Streptococcus.

F

Recommendations for anticoagulation for atrial fibrillation in valvular heart disease

NOAC (Class I, Level of Evidence A):

❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score

VKA (Class I, Level of Evidence C):

❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS

VKA:(Class IIa, Level of Evidence B) :

❑ Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement

NOAC : (Class III: Harm, Level of Evidence B)

❑ NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation

Abbreviations: NOAC: Novel oral anticoagulant; VKA: Vitamin-K antagonist; AF: Artial fibrillation

The above table adopted from 2020 AHA Guideline

Median OperativeMortality Rates for Specific Surgical Procedures

Procedure	Mortality rate (%)
AVR	2.2
AVR + CABG	4
AVR + Mitral valve replacement	9
Mitral valve replacement	5
Mitral valve replacement + CABG	9
Mitral valve repair	1
Mitral valve repair +CABG	5

Management of HFrEF

(Class I) ACE-I/ARNI Beta-blocker Mineralocorticoid receptor antagonist Dapagliflozin/Empagliflozin Loop diuretic for fluid retention

LVEF ≤35% and QRS <130 ms

LVEF >35% or device therapy not indicated or inappropriate

Sinus rhythm and LVEF ≤35% and QRS ≥130 ms

ICD implantation Ischemic (class I) Non-ischemic (class IIa)

If symptoms persist, consider therapies (class II)

CRT-D/-P QRS ≥150 ms (Class I) QRS 130-149 ms (Class IIa)

Management of patients with pulmonary edema

Oxygen (Class I) or ventilatory support (Class IIa)

Systolic blood pressure ≥110 mmHg

Yes

NO

Loop diuretics (Class I) and/or vasodilators (Class IIb)

Signs of hypoperfusion

Yes

NO

Loop diuretics (Class I) and inotropes/vasopressors(Class IIb)

Loop diuretics (Class I)

Congestion relief

Yes

NO

Optimized medical therapy

Renal replacement therapy Mechanical circulatory support Palliative therapy

The above algorithm adopted from 2021 ESC Guideline

Recommendations for initial treatment of acute heart failure

Oxygen, ventilation support (Class I, Level of Evidence C):

❑ Oxygen is recommended in hypoxic patients with SpO2<90% or PaO2 <60 mmHg ❑ Intubation is recommended in the presence of progressive respiratory failure in spite of oxygen administration or non-invasive ventilation

Oxygen, ventilation support (Class IIa, Level of Evidence B):

❑ In patients with respiratory distress (respiratory rate >25 breaths/min, SpO2<90%), non-invasive positive pressure ventilation is recommended to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation

Diuretics :(Class I, Level of Evidence C) :

❑ Intravenous loop diuretics are considered for all admitted patients with acute heart failure presented with signs, symptoms of fluid overload

Diuretics : (Class IIa, Level of Evidence B)

❑ In patients with resistant edema who do not respond to an increase in loop diuretic doses, combination of a loop diuretic with thiazide type diuretic should be considered

Vasodilators: (Class IIb, Level of Evidence B)

❑ In order to improve symptoms and reduce congestion in patients with AHF and SBP >110 mmHg, vasodilators may be considered as initial therapy

Inotropic agents : (Class 2b, Level of Evidence C)

❑ Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of hypoperfusion without response to fluid challenge, to improve [[peripheral perfusion]] and maintain end-organ function

Inotropic agents]] (Class III, Level of Evidence C):

❑ Routinely administration of inotropic agents are not recommended , due to safety concerns, unless the patient has symptomatic hypotension and evidence of hypoperfusion

Vasopressors: (ClassIIb, Level of Evidence B)

❑ In patients with cardiogenic shock, a vasopressor, preferably norepinephrine, may be indicated to increase blood pressure and vital organ perfusion

Anticoagulant therapy: (ClassI, Level of Evidence A)

❑ Thromboembolism prophylaxis such as LMWH is recommended in patients not already anticoagulated and no contraindication to anticoagulation, to prevent the risk of deep venous thrombosis and pulmonary embolism

Opiates: (ClassIII, Level of Evidence C)

❑ Opiates is not routinely recommended, unless in selected patients with severe, intractable pain or anxiety

Abbreviations: AHF: Acute heart failure; LMWH: Low-molecular-weight heparin; PaO2: Partial pressure of oxygen  ; SpO2: Transcutaneous oxygen saturation;

The above table adopted from 2021 ESC Guideline

Approach to stable chest pain and ischemia and no obstructive CAD (INOCA)

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Stable chest pain suspected INOCA

Non-invasive test more prevalent Invasive test more comprehensive

Invasive coronary functional testing

Stress PET, Stress CMR, Stress echocardiography